DOCSLIB.ORG

Primary Care After Bariatric Surgery

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Primary Care After Bariatric Surgery American College of Physicians Virginia Chapter 2013 Annual Meeting and Clinical Update March 1–2, 2013 Primary Care Follow-Up After Bariatric Surgery Puneet Puri, M.B.B.S., M.D. Assistant Professor of Medicine Division of Gastroenterology, Hepatology and Nutrition Virginia Commonwealth University, Richmond VA I have no disclosures related to current presentation Objectives • Growing burden • Different weight loss surgeries • Nutritional and metabolic consequences • Long term complications • Special populations Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008 (*BMI ≥30, or about 30 lbs. overweight for 5’4” person) 1990 1999 2008 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% BRFSS: Behavioral Risk Factor Surveillance System Relation between BMI and Mortality Lew EA. Ann Intern Med 1985;103:1024 Dealing with Obesity Epidemic Samuel I, et al Am J Surg 2006;192:657-62 Types of Bariatric Surgery Restrictive Restrictive Malabsorptive Malabsorptive Restrictive Vert Band Gastroplasty Bilio-pancreatic Diversion Over 90% in US Roux-N-Y Adjustible Gastric Band Gastric Bypass Bilio-pancreatic Diversion with Duodenal Switch Sleeve Gastrectomy Parameter RYGBP BPD-DS VBG LAGB Weight Loss % EBW 65-70 ~70 50-60 50 % BMI 35 ~35 25-30 25 SI except fibrosis, SI NAFLD SI SI may get worse SI or R SI or R I or R Diabetes SI or R 65-95% 65-95% 40-65% Operative Mortality 0.5-1% 1% 0.1% 0.1% Morbidity 5% 5% 5% 5% Complication Stomach dilation, Malabsorption Food/pill Gastric prolapse, ventral hernia Increased AST/ALT, impaction stomal obstruction, resolve after 6 mths Outlet obstruction pouch dilation Type Restrictive/ Malabsorptive / Restrictive Restrictive Malabsorptive Restrictive Use in the United 9% 87% 2% 1.4% States Gastric Bypass Surgery The Concept Gastrojejunostomy Jejuno-jejunal anastomosis Proximal RNYGB Roux-en-Y gastric bypass (RYGB) Ghrelin GLP-1 PYY Insulinn Meirelles K. et al. Mechanisms of Glucose Homeostasis after Roux-en-Y Gastric Bypass Surgery in the obese, insulin-resistant Zucher Rat. Ann Surg 2009 February;249(2):277-285. Case 1 • A 38-yo Caucasian female • Eight month history of ascites • Gastric bypass in 1999 at outside facility • Complaints: – Leg swelling – Increased forgetfulness – Unsteady on feet – Recurrent falls recently – Weak and tired Case 1 • On exam: – 98 lb, 5’3” – Poor dentition & oral hygiene – Muscle wasting – Spider angioma – Ecchymosis – Ascites and edema – Asterixis + • Labs: – Hb 9.7, Plt 106, INR 1.4, Cr 1.0 – AST 46, ALT 33, TBil 1.5, Alb 2.4 – Ascitic fluid alb <1.0, protein 1.9 • Cirrhosis, MELD 12, Child C • Admitted 1 month later with sepsis, had complicated hospital course and after 5 weeks family decided for comfort care Case 1 • 243 lb, lost 103 lb in first year after gastric bypass • Since surgery, had seen PCP at scheduled appointments but no follow up with surgeons • Current BMI 16.3 kg/m2 • Drinks 3-4 cans of beer/day, low vitamin B12 • Poor diet and nutrient supplements • Decompensated Alcoholic cirrhosis • Severe protein calorie malnutrition and cachexia • Vitamin B12 deficiency Take Home Message - Case 1 • Patient compliance for successful outcome – Follow up visits with the surgeon and physicians – Diet and nutrition – Alcohol abstinence • Always know the surgical details/anatomy • Significant excess weight loss? • Physician awareness Case 2 • A 33-yo WF, referred for nutritional management • Gastric bypass in 2006 • C/o nausea, vomiting, abdominal pain, bloating • Leg swelling and abdominal distension • Unable to eat well due to above complaints • Alcohol abuse until 10 months ago • Pallor, abd distended, tender, BS+, edema, asterixis + • Hb 9.6, Plt 122, AST/ALT 126/59, TBil 1.8, AlkP 187, Albumin 2.8, INR 1.4, Cr 1.1 • US abd: small nodular liver, perihepatic fluid, reversal of portal flow with portal vein 15 mm, spleen 13.8 cm Case 2 Small bowel obstruction at the distal small bowel anastomosis: dilated Roux jejunal limb and excluded limb. Venting gastrostomy tube by IR Liquid diet, tolerated well initially, then became non-compliant High surgical risk for bowel surgery, liver transplant evaluation initiated to address both liver and bowel issues Initiated on TPN Developed sepsis and did not survive The ABC System of Classification of Small Bowel Obstruction A Alimentary limb B biliopancreatic limb C Common channel Tucker ON, et al Obes Surg 2007;17:1549–1554 Alcohol Misuse After Bariatric Surgery: Epiphenomenon or “Oprah” Phenomenon? • Lack of robust data • Alcohol pharmacokinetics study in women with gastric bypass ≥3 years • Compared to age and BMI matched controls, blood alcohol levels – Peaked more quickly – Remained higher • About 90% gastric bypass patients more sensitive to alcohol after surgery Klockhoff H et al. Br J Clin Pharm 2002; 54 , pp. 587–591 Buffington C et al. Surg Obes Rel Dis 2006;2: 313. Case 3 • 25-yo AAF, had distal gastric bypass 6 months ago • Lost 164 lbs (459 lb to 285 lb) • Admitted with nausea, vomiting, poor oral intake and abdominal pain ~5-6 weeks • Obese, lethargic, apathetic, weakness of extremities 4-/5 • BUN 5, Cr 0.6, Lactate 4.5, Albumin 2.8, Pre-albumin 9, AST/ALT 35/39 Thiamine Deficiency • Thaimine levels: Low • Thiamine replacement: Gradually improved, lactic acidosis resolved • Thiamine deficiency can cause – Peripheral neurologic – Cerebral – Cardiologic – Gastrointestinal manifestations • Thiamine is absorbed in the small intestine, mostly in the jejunum and ileum. • Even VBG procedures have been associated with thiamine deficiency, probably due to reduced intake, not malabsorption Clinical Presentations of Thiamine Deficiency Beriberi Subtype Symptoms and Findings Neuropsychiatric Hallucinations/aggressive behavior Confusion/nystagmus/ataxia/ophthalmoplegia Wet beriberi Tachycardia/respiratory distress/leg edema Right ventricular dilation/lactic acidosis Dry beriberi Numbness/muscle weakness and pain of lower to upper extremities/convulsions/Exaggerated tendon reflexes Gastrointestinal Nausea/emesis and megajejunum Constipation and megacolon Bariatric beriberi Symptoms corrected by antibiotics, not by oral thiamine Thiamine Deficiency • Wernicke encephalopathy is caused by severe thiamine deficiency • Classical clinical triad – Ocular changes (nystagmus, ocular nerve palsies), – Ataxia – Aapathetic mental confusion • As early as 2 weeks and as long as 13 years after surgery • Fatalities have been reported • Early recognition and immediate parenteral treatment • Prevention: Multivitamin supplement is adequate • Deficiency: parenteral thiamine 50 to 200 mg per day until symptoms clear, then 10 to 100 mg by mouth daily Famous Words of a Bariatric Surgeon… In more than 2,000 RYGB procedures, we never saw any evidence of protein-calorie malnutrition, unless the patient had a mechanical problem with excessive vomiting or had undergone a distal gastric bypass Harvey Sugerman, Former Vice Chair Department of Surgery, VCU Medical Center Letter J Am Coll Surg Nov 2005 Protein Calorie Malnutrition in Gastric Bypass Patients • A real risk • Some patients suffer troublesome vomiting after surgery, until their GI tract adjusts to the changes, and cannot eat adequate amounts even with 6 meals a day • Many patients require protein supplementation during the early phases of rapid weight loss, to prevent excessive loss of muscle mass • Patient compliance and dedicated team can prevent this Medication Management • Prevention of gallstone formation • Diabetes • Hypertension • Dyslipidemia • Monitor closely for diuretics • No NSAIDs Luminal Complications of Gastric Bypass • Anastomotic – Leak – Stricture/stenosis – Ulcer • Obstruction – Internal herniation – Adhesions • Dumping syndrome Anastomotic Ulcer Anastomotic Ulcer • In up to 16% of patients. Possible causes include: – Altered blood supply to the anastomosis – Anastomotic tension – Gastric acid – Helicobacter pylori – Smoking – Use of Non-steroidal anti-inflammatory drugs • Treatment: – Use of Proton pump inhibitors – Use of a cytoprotectant and acid buffering agent – Temporary restriction of the consumption of solid foods Anastomotic Stricture • If the inflammation and healing process outpaces the stretching process, scarring may result in stricture formation • Treatment: EGD and dilation Internal Herniation Mesenteric Swirl Sign and Mushroom-shaped mesenteric root. Enhanced transverse CT scan through mesenteric root shows narrowed mesenteric root with fat and vessels passing between superior mesenteric artery (arrow) and distal mesenteric arterial branch (arrowhead) Nutritional Aspects of Bariatric Surgery • Diet recommendation at VCU Medical Center: • Day of surgery: – No food or drink • Day 1 after surgery: (Category 1) – 1/4 cup clear liquids or juice per hour (2 small medicine cups). • Day 2 after surgery: (Category 2) – Full liquid diet (to be followed for 2 full weeks after surgery) Category III – Up to 2 weeks post Gastric Bypass • Full liquid diet (sugar free) • Minimum daily protein intake – Women: 50-60 grams – Men: 65-75 grams • No juice • No sweetened beverages Category IV: 2-4 weeks post Gastric Bypass • Pureed diet (consistency of applesauce) • Minimum daily protein intake – Women: 50-60 grams – Men: 65-75 grams • No juice • No sweetened beverages Category V: After 4 weeks of Gastric Bypass • Regular foods with emphasis on avoiding more difficult to tolerate foods – Meat, Chicken – Bread, Pasta, Rice – Pork, Firm fish • Minimum daily protein intake – Women: 50-60 grams, Men: 65-75 grams • No juice • No sweetened beverages • Avoid sugar, junk, high calorie processed
Load more

Recommended publications
  • The Politics of Beer: Analysis of the Congressional Votes on the Beer Bill of 1933
    Public Choice https://doi.org/10.1007/s11127-017-0493-1 The politics of beer: analysis of the congressional votes on the beer bill of 1933 1 2 3 Eline Poelmans • John A. Dove • Jason E. Taylor Received: 26 June 2017 / Accepted: 4 December 2017 Ó Springer Science+Business Media, LLC, part of Springer Nature 2017 Abstract Nine days after he took office in March 1933, Franklin Roosevelt asked Con- gress to amend existing federal Prohibition policy so as to allow for the sale and con- sumption of 3.2% alcohol beer. Over the following 8 days, the so-called ‘‘beer bill’’ was proposed, debated, passed and signed into law. This study analyzes the political decision making behind one of FDR’s earliest New Deal policies. Specifically, we consider how voter preferences, representatives’ ideologies, national party affiliations, and the influence of special interests affected legislative decision making. We find that special interests and party affiliations were particularly important drivers of congressional voting behavior. Keywords Beer legalization Á Prohibition Á Special interests Á Median voter Á Representative ideology Á New Deal Á Franklin Roosevelt Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11127-017- 0493-1) contains supplementary material, which is available to authorized users. & Jason E. Taylor [email protected] Eline Poelmans [email protected] John A. Dove [email protected] 1 LICOS Centre for Institutions and Economic Performance, Faculty of Economics and Business, Campus Brussels,
    [Show full text]
  • Maria ABRAHAMSON Centre for Social Research on Alcohol and Drugs (Sorad), Stockholm University, Sweden
    Maria ABRAHAMSON Centre for Social Research on Alcohol and Drugs (SoRAD), Stockholm University, Sweden PERCEPTIONS OF HEAVY DRINKING AND ALCOHOL PROBLEMS AMONG YOUNG ADULTS Data from focus groups is presented. Interviews have been conducted in different regions of Sweden with young men and women from different social groups. The groups are composed of naturally existing networks of friends. Excerpts from feature films showing young people in various typical drinking situations have directed the group discussions. In the paper an analysis of the group’s perception of heavy drinking and alcohol problems is presented. The results indicate that how they speak of their own drinking is of importance for how they perceive the transition in others from being heavy drinkers to having alcohol problems. Keywords: young adults, alcohol, focus groups SESSION: 12.2 Salme AHLSTRÖM, Leena Metso, Eeva Liisa Tuovinen Alcohol and Drug Research, National Research and Development Centre for Welfare and Health, Helsinki, Finland FAMILY VALUES AND US E OF LEGAL AND ILLEGAL DRUGS AMONG YOUTH Aims. This paper examines the role of family values in use of legal and illegal drugs among youth. Adolescents’ use of tobacco, alcohol and drugs is related to many factors, from genetic and psychological to social and environmental factors. Family is one of the most important domains, which is influencing adolescent's behavior. To examine family values is therefore of great importance when we want to understand to which factors the use of legal and illegal drugs are related in adolescents. The relationship between integration of family life, values and use of alcohol and other drugs among Finnish students are examined.
    [Show full text]
  • SSAGA-I Specifications
    Semi-Structured Assessment for the Genetics of Alcoholism Specifications Louise J. Laster Ines G. Janca Kathleen K. Bucholz, Ph. D. and Interviewers from all C.O.G.A. sites: S.U.N.Y Brooklyn: Cynthia Purcell U. Connecticut: Linda Mahoney Michelle Slivinsky U.C. San Diego: Nancy Bacon Estee Shapiro U. Indiana: Carolyn York Donna Clair U. Iowa: Angie Cookman Ellen Kapp Washington University: Laura Kaplan Revised 1/20/93 SSAGA: GENERAL SPECIFICATIONS The Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA) is an instrument designed to assess physical, psychological and social manifestations of alcohol abuse or dependence and other psychiatric disorders. It is a semi- structured interview which capitalizes on prior research in psychiatric epidemiology. As such, it relies heavily on items previously validated by other research interviews, including DIS, CIDI, HELPER, SAM, SADS, and SCID. FORMAT: The interview is formatted with an index in the left margin, questions in the center, and coding space in the right margin. The index is there to refer questions to the respective criteria in the respective diagnostic systems. Since the SSAGA is polydiagnostic, the left margin codes will reveal which diagnostic system, and which particular criterion each question covers. The following key applies: DIAGNOSTIC SYSTEMS: 3R = DSM-III-R DSM = DSM-III FGN = Feighner RDC = Research Diagnostic Criteria ICD = ICD-10 SYMPTOM CRITERIA: These appear at the end of the index code: e.g. AD3RA4 = Alcohol Dependence, DSM-III-R system, criterion A, item 4. RDCALC = Research Diagnostic Criteria system, Alcohol DSMALC = DSM-III, Alcohol FGNALCC2= Feighner system, Alcohol, criterion C, item 2.
    [Show full text]
  • PHN Webinar 3 D&A
    Assist D&A (& comorbid MH) primary care treatment AMANDA Assist - D&A (& comorbid MH) Professor Amanda Baker Conjoint Professor Adrian Dunlop Andrew Taylor Clinical Psychologist & Area Director, Drug & Alcohol Clinical Nurse Consultant, Academic, UoN) Clinical Services, HNE Health Drug & Alcohol Clinical Services, HNE Health Amanda Amanda AMANDA Re-cap: ASK - 6th Feb 2018 Ask • Substance use is common in GP setting • How to approach patients: SNAP, other Drugs • What, how oFten, how much, how? • Substance use DisorDer: harmFul use or DepenDence? • Co-morbidities • (screening tools e.g. AUDIT – alcohol) AMANDA Re-cap: ADVISE - 13th March 2018 Advise • Brief interventions: effective • Motivational Interviewing • Ambivalence • Nursing role in drug and alcohol, SNAP • Patient’s motivation to change • Goals setting AMANDA Assist • Treatment is effective • Combination of pharmacotherapy and counselling effective • Treatment may need to be longer and repeated as the person may not have made as many change attempts • Context of stress management is important (overlap of symptoms of mental illness and withdrawal) AMANDA Assist • Monitor mental health symptoms and smoking, alcohol and other drug use; adverse side effects of psychotropic medication • Refer to Quitline; D&A Services etc and maintain ongoing relationship • At the beginning of treatment sometimes mental health symptoms can seem a bit worse – talk about this, normalize it, monitor • People begin to feel mentally and physically better AMANDA Assist • Sustaining change – grief (show understanding,
    [Show full text]
  • The Effects of Stress and Placebo Alcohol on Cognitive Activation and Inhibitory Control in Male Problem Gamblers and Problem Gamblers with Alcohol Use Disorder
    The Effects of Stress and Placebo Alcohol on Cognitive Activation and Inhibitory Control in Male Problem Gamblers and Problem Gamblers with Alcohol Use Disorder by Lindsay Steinberg A thesis submitted in conformity with the requirements For the degree of Master of Science Graduate Department of Pharmaceutical Sciences University of Toronto © copyright by Lindsay Steinberg (2009) Library and Archives Bibliothèque et Canada Archives Canada Published Heritage Direction du Branch Patrimoine de l’édition 395 Wellington Street 395, rue Wellington Ottawa ON K1A 0N4 Ottawa ON K1A 0N4 Canada Canada Your file Votre référence ISBN: 978-0-494-59601-2 Our file Notre référence ISBN: 978-0-494-59601-2 NOTICE: AVIS: The author has granted a non- L’auteur a accordé une licence non exclusive exclusive license allowing Library and permettant à la Bibliothèque et Archives Archives Canada to reproduce, Canada de reproduire, publier, archiver, publish, archive, preserve, conserve, sauvegarder, conserver, transmettre au public communicate to the public by par télécommunication ou par l’Internet, prêter, telecommunication or on the Internet, distribuer et vendre des thèses partout dans le loan, distribute and sell theses monde, à des fins commerciales ou autres, sur worldwide, for commercial or non- support microforme, papier, électronique et/ou commercial purposes, in microform, autres formats. paper, electronic and/or any other formats. The author retains copyright L’auteur conserve la propriété du droit d’auteur ownership and moral rights in this et des droits moraux qui protège cette thèse. Ni thesis. Neither the thesis nor la thèse ni des extraits substantiels de celle-ci substantial extracts from it may be ne doivent être imprimés ou autrement printed or otherwise reproduced reproduits sans son autorisation.
    [Show full text]
  • EXAMINING PROHIBITION in 1920S USA Michael Sweet School of Law
    A MEASURE OF SUCCESS: EXAMINING PROHIBITION IN 1920s USA Michael Sweet School of Law Murdoch University This thesis is presented for the degree of Master of Laws by Research Murdoch University, 2017 ii Declaration I declare that this thesis is my own account of my research and contains as its main content work which has not previously been submitted for a degree at any tertiary educational institution. Michael Sweet 2017 iii Abstract In 1919, a policy to ban alcoholic beverages was entrenched by Congress into the Constitution - the 18th Amendment. Congressmen Andrew Volstead proceeded to promote the enacting legislation in the United States House of Representatives, and the National Prohibition Act became law. Does Prohibition deserve its overwhelming condemnation as a failure? How successful was the Act’s implementation? After the introduction, part two discusses the theories and perceptions that serve to shape the debate over alcohol prohibition. To measure its success, the Act is then examined according to its outcomes - part three of the thesis assesses the anticipated increase in economic prosperity through the metrics of government revenue, business activity, workplace attendance, wages and sales figures. Part four scrutinises the production and supply of alcohol, prison populations, drunkenness, crime rates and corruption. The success of a reform is also found in how it shapes the nation. Prohibition’s economic and political effects are briefly noted, as is its influence upon policing and the judiciary. The 21st Amendment repealing alcohol prohibition functioned to skew reporting of the Prohibition era, serving the purposes of ideologues and business opportunists. The thesis concludes that the reform was not defeated by any inherent impossibility, but rather by a lack of skilfully wielded political will.
    [Show full text]
  • This Bud's for Who? Craft Brewing and the Transformation of the American Beer Industry
    Johnson & Wales University ScholarsArchive@JWU Honors Theses - Providence Campus College of Arts & Sciences 2018 This Bud's For Who? Craft rB ewing and the Transformation of the American Beer Industry Joshua E. Orel Johnson & Wales University - Providence, [email protected] Follow this and additional works at: https://scholarsarchive.jwu.edu/student_scholarship Part of the Arts and Humanities Commons Repository Citation Orel, Joshua E., "This Bud's For Who? Craft rB ewing and the Transformation of the American Beer Industry" (2018). Honors Theses - Providence Campus. 32. https://scholarsarchive.jwu.edu/student_scholarship/32 This Honors Thesis is brought to you for free and open access by the College of Arts & Sciences at ScholarsArchive@JWU. It has been accepted for inclusion in Honors Theses - Providence Campus by an authorized administrator of ScholarsArchive@JWU. For more information, please contact [email protected]. This Bud's For Who? Craft Brewing and the Transformation of the American Beer Industry By Joshua E Orel Advisor: Dr. Ann Kordas Submitted in partial fulfillment of the requirement for the ‘University Honors Scholar’ designation at Johnson & Wales University 2018 Orel 1 Table of contents Acknowledgements 2 Abstract 3 Introduction 4 History 7 Big Beer: How We Got Here 15 Current State 24 Where We’re Going 32 Conclusion 38 Works Cited 39 Orel 2 Acknowledgements This thesis would not have been possible without the support of various Johnson & Wales University professors including, but not limited to, Dr. Ann Kordas, Dr. Wendy Wagner, and Dr. Kristi Girdharry. I would also like to thank my various chefs throughout my young career including Chef Kari Naegler of Wegmans Food Markets and Chef Steven Johansson of Johnson and Wales University for teaching me a love of all things delicious.
    [Show full text]
  • Alcohol Consumption and Lung Cancer: a Review of the Epidemiologic Evidence1
    Vol. 10, 813–821, August 2001 Cancer Epidemiology, Biomarkers & Prevention 813 Review Alcohol Consumption and Lung Cancer: A Review of the Epidemiologic Evidence1 Elisa V. Bandera,2 Jo L. Freudenheim, and John E. Vena panel of experts commissioned by the World Cancer Research Department of Nutritional Sciences, Rutgers University, New Brunswick, New Fund and the American Institute for Cancer Research, after Jersey 08901 [E. V. B.], and Department of Social and Preventive Medicine, reviewing the epidemiological evidence, concluded in 1997 that School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, alcohol intake may “possibly” increase lung cancer risk (3). We New York 14214 [J. L. F., J. E. V.] conducted a comprehensive review to evaluate the current epidemiological evidence regarding alcohol consumption as a risk factor in lung cancer etiology and to identify gaps in that Abstract research. A role for alcohol consumption in lung cancer etiology has been suggested in some studies, but this possible relationship has been often regarded with skepticism, Materials and Methods with any indication of an association being attributed In preparing this review we followed published guidelines for to confounding by cigarette smoking. The purpose of review papers (4–7). Our literature search was limited to En- this work was to review the epidemiological evidence for glish-language, peer-reviewed publications. Studies were iden- an association of alcohol and lung cancer and to tified mainly through electronic searches on Medline (1966– identify gaps in that research. The studies reviewed here 2000) complemented with manual searches of references in provide some indication that alcohol and particularly other published articles.
    [Show full text]
  • Abstract Positive and Negative Outcomes of Alcohol
    ABSTRACT POSITIVE AND NEGATIVE OUTCOMES OF ALCOHOL CONSUMPTION AMONG COLLEGE STUDENTS ON CELEBRATION DAYS COMPARED TO TYPICAL DAYS by Kathryn Alexandra Witmer College students experience both positive and negative consequences in each drinking occasion. In a longitudinal study, 62 college students reported on their alcohol consumption patterns and experience of positive and negative consequences over the course of 7 weeks. Celebration day alcohol consumption and consequences relates to typical day experiences. Blackout experiences were most commonly reported during the baseline assessment. In addition, heavy and light drinkers did not differ across consequences on celebrations days. College and universities might use this information to tailor interventions and develop prevention strategies with respect to celebration days. Implications are discussed. POSITIVE AND NEGATIVE OUTCOMES OF ALCOHOL CONSUMPTION AMONG COLLEGE STUDENTS ON CELEBRATION DAYS COMPARED TO TYPICAL DAYS A Thesis Submitted to the Faculty of Miami University in partial fulfillment of the requirements for the degree of Master of Science Department of Kinesiology and Health by Kathryn Alexandra Witmer Miami University Oxford, OH 2014 Advisor _____________________________ Rose Marie Ward, PhD Advisor ______________________________ Susan Cross Lipnickey, PhD, JD Reader ______________________________ Kyle Timmerman, PhD Table of Contents Page Number Chapter One: Introduction 1 Outcomes of High-Risk Drinking 2 Celebration Drinking 4 Additional Contexts of Student Drinking 7
    [Show full text]
  • 0875865720.Algora.Publishing.Brewing.Battles.A.History.Of
    BREWING BATTLES A HISTORY OF AMERICAN BEER BREWING BATTLES A HISTORY OF AMERICAN BEER AMY MITTELMAN Algora Publishing New York © 2008 by Algora Publishing. All Rights Reserved www.algora.com No portion of this book (beyond what is permitted by Sections 107 or 108 of the United States Copyright Act of 1976) may be reproduced by any process, stored in a retrieval system, or transmitted in any form, or by any means, without the express written permission of the publisher. Library of Congress Cataloging-in-Publication Data — Mittelman, Amy. Brewing battles : a history of American beer / Amy Mittelman. p. cm. Includes bibliographical references and index. ISBN-13: 978-0-87586-572-0 (trade paper: alk. paper) ISBN-13: 978-0-87586-573-7 (hard cover: alk. paper) ISBN-13: 978-0-87586-574-4 (ebook) 1. Beer—United States--History. 2. Beer industry—United States—History. 3. Beer—Taxation—United States—History. I. Title. TP573.U6M58 2007 641.2’309—dc22 2007036283 Front Cover: Top: Bub’s BBQ, Sunderland, MA. by Alan Berman Bottom: Smiling woman with beer glass © Emely/zefa/Corbis Back Cover: Author photo by Andrea Burns. Printed in the United States This book is dedicated to the memory of my parents, Beatrice and Louis Mittelman TA B LE OF CONTENTS INTRODUCTION 1 CH APTER 1. EVERY MAN HIS OWN BREWER : BREWING IN T H E UNITED STATES DURING T H E COLONIAL , EARLY NATIONAL , AND ANTE B ELLUM PERIODS 5 CH APTER 2. MORALITY FOLLOWS IN T H E WAKE OF MALT LIQUOR : TH E BREWING INDUSTRY AND T H E FEDERAL GOVERNMENT 1862–1898 23 CH APTER 3.
    [Show full text]
  • An Internist's Guide to Unhealthy Alcohol
    An Internist’s Guide to Unhealthy Alcohol Use Ryan Graddy, MD JHU SOM Disclosures • None Learning Objectives • Understand the terminology used to describe unhealthy alcohol use • Identify means of screening for alcohol use disorder • Describe the utility of brief primary care-based interventions for unhealthy alcohol use • Achieve familiarity with FDA-approved medications for alcohol use disorder Patient DM • 58 year old man with hypertension, depression, and bilateral hearing loss s/p bilateral cochlear implants • Drinks 24-48oz beer daily, often drinks after walking dogs in the morning • Niece reports he is drinking substantially more • Denies any legal, social, work, or medical consequences of his alcohol use Patient RW • 43 year old man with hypertension, chronic hepatitis C recently treated with cure, anxiety, and opioid use disorder on Suboxone maintenance • History of heavy alcohol (72oz beer/day) use since late teens with up to 90 days of sobriety in the past without specific treatment • Previous legal (DUI) and employment issues related to his alcohol use • Has tried to quit cold turkey but gets tremors Outline • Epidemiology • Language and terminology • Screening • Treatment Epidemiology • 138M (52%) individuals ≥ 12 years old have used alcohol in the past month • > 88K alcohol-related deaths annually • Responsible for 1 in 10 deaths of adults aged 20-64 • 3rd leading cause of preventable death • $249B in costs in 2010 SAMHSA, NSDUH 2015. Centers for Disease Control and Prevention. ARDI, 2013. Stahre M, et al. Prev Chron Dis 2014. Language and Terminology • Unhealthy alcohol use • Risky use • Men < 65 - ≥ 14 standard drinks/week on average or ≥ 4 drinks on any day • Women, and men ≥ 65 - ≥ 7 standard drinks/week on average or ≥ 3 drinks on any day • Alcohol use disorder – a pattern of alcohol use leading to clinically significant impairment or distress, as manifested by multiple psychosocial, behavioral, or psychologic features Saitz R.
    [Show full text]
  • Thats the Spirit : Creative Sauteing with Beer, Wine and Liquor Pdf, Epub, Ebook
    THATS THE SPIRIT : CREATIVE SAUTEING WITH BEER, WINE AND LIQUOR PDF, EPUB, EBOOK Chef Ho | 76 pages | 12 Jul 2012 | Outskirts Press | 9781432784003 | English | Parker CO, United States Thats the Spirit : Creative Sauteing with Beer, Wine and Liquor PDF Book Bekijk de hele lijst. He lives in Berlin. Jason Treat, Ryan T. However, Belgian production of whisky is a much more recent phenomenon. Bourbon , in this case, is a fitting option for both sweet and sour recipes, but there is no denying that it goes best with fruit. Thin-skinned fruits such as berries or peaches will over soften if they sit in alcohol for too long, but hardier fruits such as figs will stand up longer. Tags: radio whiskey, drink, cartoon, beverage, beverage drink, alcoholic drink, radio player, radio transmitter, cartoon object, objects, relaxing, electronics, cold drink. Tags: lithographs, vintage ads, vintage advertising, vintage advertisements, liquor ads, beer ads, brewing, brewery, ale, lager, beer, scotch, vodka, gin, whiskey, grain alcohol, alcoholic beverage, mixed drinks, bar, bars, bar signs, restaurants, business advertisements, jeanpaul ferro, advertising art, vintage, collectible, ad, antique ads, americana, kitchen, advertising, cocktail, asti, cinzano, champagne, spirits, aperitifs, cognac, leonetto, cappiello, vichy, spumante, vermouth, contratto, bianco, red wine, white wine, restaurant, gancia. Tags: wine, glass, watercolor, alcohol, drink, drinking, colorful, wine glass, beverage, champagne, drinks, glass of wine, glasses, glassware, wineglass, alcoholic beverage, alcoholic drink, abstract art, a wine glass, celebration. Muddy sediment at the bottom of the pitcher resembles wet muesli. Tags: alcohol, alcoholic, bar, beverage, collection, cosmopolitan, drink, flat, glass, ice, juice, lemon, lime, margarita, martini, menu, set, summer, symbol, tropical, vector, vodka.
    [Show full text]